Provider Demographics
NPI:1649760331
Name:HIGH DESERT PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:HIGH DESERT PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:MEGAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FLESCH
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:920-277-5809
Mailing Address - Street 1:111 N PARK ST STE B
Mailing Address - Street 2:
Mailing Address - City:CORTEZ
Mailing Address - State:CO
Mailing Address - Zip Code:81321-3340
Mailing Address - Country:US
Mailing Address - Phone:920-277-5809
Mailing Address - Fax:
Practice Address - Street 1:111 N PARK ST STE B
Practice Address - Street 2:
Practice Address - City:CORTEZ
Practice Address - State:CO
Practice Address - Zip Code:81321
Practice Address - Country:US
Practice Address - Phone:920-277-5809
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-17
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO55180876Medicaid